What is the admitting impression and plan for a 65-year-old female (F) with a history of hypertension, who presents with a 4-day history of nonproductive cough, throat itchiness, progressive dyspnea, easy fatigability, and facial swelling, and a chest X-ray showing a pleural effusion?

Admitting Impression and Initial Management Plan

Primary Admitting Impression

The most likely diagnosis is community-acquired pneumonia (CAP) with parapneumonic effusion, though superior vena cava (SVC) syndrome from underlying malignancy must be urgently excluded given the facial swelling. 1, 2

Differential Diagnoses to Consider

High Priority (Rule Out Immediately)

• SVC syndrome from malignancy - The combination of facial swelling, dyspnea, and pleural effusion in a 65-year-old raises concern for lung cancer with mediastinal involvement 3
• Pulmonary embolism (PE) - Dyspnea, nonproductive cough, and pleural effusion are present in 46% of PE cases; facial swelling could represent SVC thrombosis 3
• Acute decompensated heart failure - Hypertension history with dyspnea, fatigue, and pleural effusion suggests cardiac origin 3
• Parapneumonic effusion/empyema - Progressive symptoms with cough and effusion require immediate evaluation 1, 4

Secondary Considerations

• Tuberculosis - Must be considered with any pulmonary infiltrate, fever, and cough 2
• Malignant pleural effusion - Age and presentation warrant evaluation 3, 1

Immediate Diagnostic Workup

Laboratory Studies (Stat)

• Complete blood count with differential - Look for leukocytosis (bacterial pneumonia) or thrombocytopenia (PE) 3, 4
• NT-proBNP or BNP - Values ≥1500 pg/mL suggest cardiac origin; <1500 pg/mL makes heart failure less likely 3
• Troponin, basic metabolic panel, liver function tests 3, 4
• Arterial blood gas - 75% of PE patients have hypoxemia, though 20% have normal PaO2 3
• D-dimer - If elevated with high clinical suspicion, proceed to CT angiography 3
• Blood cultures x2 before antibiotics 4, 2

Imaging Studies (Urgent)

• CT chest with IV contrast (venous phase) - Essential to evaluate for:

  • SVC obstruction or thrombosis (explains facial swelling) 3
  • Mediastinal mass or lymphadenopathy 3
  • Pulmonary embolism (if D-dimer elevated) 3
  • Pleural effusion characteristics and lung parenchyma 3
  • Consider CT chest/abdomen/pelvis if malignancy suspected 3

• Thoracic ultrasound at bedside - Perform immediately to:

  • Confirm effusion size and character 3, 1
  • Assess for pleural nodularity (suggests malignancy) 3
  • Evaluate cardiac function and look for B-lines (suggests heart failure) 3
  • Guide safe thoracentesis 1

• Echocardiography - Obtain after stabilization unless hemodynamically unstable 3

  • Assess left ventricular function, valvular disease 3
  • Evaluate for right heart strain (PE) 3

Diagnostic Thoracentesis

Perform ultrasound-guided diagnostic thoracentesis using 21G needle if effusion is safe to tap 1

Send pleural fluid for:

• Protein, LDH, pH, glucose - Distinguish transudate vs exudate 1, 5
• Cell count with differential 1, 5
• Gram stain, acid-fast bacilli stain 1, 2
• Aerobic/anaerobic cultures in blood culture bottles 1
• Cytology 3, 1

Critical: Never remove >1.5L during single thoracentesis to prevent re-expansion pulmonary edema 1

Immediate Management

Empiric Antibiotic Therapy

Start immediately without waiting for culture results: 4, 2

• Beta-lactam PLUS macrolide:
  • Ceftriaxone 1-2g IV daily PLUS azithromycin 500mg IV daily 4, 2
  • Alternative: Amoxicillin-clavulanate 1.2g IV q8h PLUS clarithromycin 500mg IV q12h 4

If severe CAP or septic shock present, escalate to:

• Piperacillin-tazobactam 4.5g IV q6h OR cefepime 2g IV q8h PLUS azithromycin or levofloxacin 4

Respiratory Support

• Supplemental oxygen to maintain SpO2 ≥90% 4, 2
• Monitor for respiratory distress requiring ICU admission 4, 2
• Consider non-invasive ventilation if PaO2/FiO2 150-300 with moderate distress 4

Specific Management Based on Effusion Type

If parapneumonic effusion confirmed (pH <7.2 or glucose <3.3 mmol/L):

• Immediate hospitalization required 1
• Insert small-bore chest tube (14F or smaller) for drainage 1
• Continue IV antibiotics with Streptococcus pneumoniae coverage 1

If transudative effusion from heart failure:

• Diuretics to treat underlying condition 1
• Therapeutic thoracentesis only if symptomatic (limit 1.5L) 1

If malignant effusion suspected:

• Perform therapeutic thoracentesis first to assess symptom relief 1
• Defer definitive intervention until diagnosis confirmed 1

Critical Pitfalls to Avoid

• Do not delay CT chest - Facial swelling with pleural effusion mandates urgent evaluation for SVC syndrome 3
• Do not assume bilateral effusions are transudative - Unilateral or asymmetric effusions require thoracentesis unless clearly transudative on clinical grounds 3, 1
• Do not drain >1.5L at once - Risk of fatal re-expansion pulmonary edema 1
• Do not delay antibiotics - Start empiric therapy immediately for suspected CAP 4, 2
• Monitor elderly patients closely - Increased risk of complications with cardiac disease and hypertension 1
• Consider PE even with normal chest X-ray - 20% of PE patients have normal radiographs 3

Admission Orders

• Admit to telemetry floor (or ICU if severe CAP criteria present) 4
• NPO until SVC syndrome excluded (may need urgent intervention)
• Continuous pulse oximetry 4
• Strict intake/output monitoring 3
• Daily weights 3
• Elevate head of bed 30-45 degrees 3